Corrective Action Plans

Finding 1164477 (2024-002)

Material Weakness 2024

East River Road Housing Development Fund Company,inc.

NY

HUD Housing Programs Eligibility

2024-002: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and signatures, as required by HUD regulations, were missing from Form HUD-50059, Owner’s Certification of Compliance. Additionally, our testing indicated that the required deposits to the replacement res...

2024-002: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and signatures, as required by HUD regulations, were missing from Form HUD-50059, Owner’s Certification of Compliance. Additionally, our testing indicated that the required deposits to the replacement reserve account had not been made for the last quarter of the Corporation’s fiscal year for any tenants. Recommendation: We recommend the Corporation establish procedures and internal controls to ensure that all required documentation is maintained, and all required reserve deposits are made timely, in accordance with HUD requirements. Action Taken: Management concurs with this recommendation. Since assuming property management on June 1, 2025, ULREDC has conducted a tenant file audit. All property management staff have been properly trained to ensure compliance with certification, documentation, and inspection requirements. Missing documentation, including Form HUD-50059, income verifications, and leasing inspections, is being corrected. Replacement reserve deposits were delayed because properties were not cash flowing. As leasing stabilizes, deposits will resume and be verified once RealPage is fully active. RealPage will serve as the compliance and record-retention platform. Quarterly internal compliance reviews will be instituted to confirm file accuracy and documentation completeness.

View Audit 374022

Finding 1164473 (2024-002)

Material Weakness 2024

Akeley Landing Housing Development Fund Company, Inc.

NY

Questioned Costs HUD Housing Programs Eligibility

2024-002: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing, and none of the required documentation to determine eligibility, as required by the HUD regulations, was provided. Additionally, our testing indicated that the required deposits to the replacement reserve ...

2024-002: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing, and none of the required documentation to determine eligibility, as required by the HUD regulations, was provided. Additionally, our testing indicated that the required deposits to the replacement reserve account had not been made for the last quarter of the Corporation’s fiscal year for any tenants. Recommendation: We recommend the Corporation establish procedures and internal controls to ensure that all required documentation is maintained, and all required reserve deposits are made timely, in accordance with HUD requirements. Action Taken: Management concurs with this recommendation. Since assuming property management on June 1, 2025, ULREDC has conducted a tenant file audit. All property management staff have been properly trained to ensure compliance with certification, documentation, and inspection requirements. Missing documentation, including Form HUD-50059, income verifications, and leasing inspections, is being corrected. Replacement reserve deposits were delayed because properties were not cash flowing. As leasing stabilizes, deposits will resume and be verified once RealPage is fully active. RealPage will serve as the compliance and record-retention platform. Quarterly internal compliance reviews will be instituted to confirm file accuracy and documentation completeness.

View Audit 374016 Questioned Costs: $1

Finding 1164422 (2024-006)

Material Weakness 2024

Reach Community Development, Inc.

OR

Eligibility Significant Deficiency

Finding No. 2024-006 Housing Trust Fund Program Federal Assistance Listing Number #14.275 Statement of Condition In connection with our lease file review, we noted two instances of four tenants tested where management did not provide support that they performed a 3rd party income verification in acc...

Finding No. 2024-006 Housing Trust Fund Program Federal Assistance Listing Number #14.275 Statement of Condition In connection with our lease file review, we noted two instances of four tenants tested where management did not provide support that they performed a 3rd party income verification in accordance with policy. Corrective Action Plan As a result of the 2024 audit, a new process is set up to ensure that new employees receive HUD annual training. Management will continue to ensure that 3rd party income verification is performed in accordance with policy.

View Audit 373851

Finding 1164421 (2024-005)

Material Weakness 2024

Reach Community Development, Inc.

OR

Eligibility HUD Housing Programs Material Weakness

Finding No. 2024-005 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner was unable to provide a listing that detailed the available to HOME tenants the contracted number and type of HOME units and therefore we were unable to test the H...

Finding No. 2024-005 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner was unable to provide a listing that detailed the available to HOME tenants the contracted number and type of HOME units and therefore we were unable to test the HOME program compliance for the audit year. Corrective Action Plan REACH utilizes a 3rd party property management company to manage the two properties located in Washougal, Washington. Management is setting up a new process to ensure that the 3rd party property management company can provide all required information.

View Audit 373851

Finding 1164420 (2024-004)

Material Weakness 2024

Reach Community Development, Inc.

OR

Eligibility HUD Housing Programs Significant Deficiency

Finding No. 2024-004 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner did not make available to HOME tenants the contracted number and type of HOME units. This is considered a temporary noncompliance as follows: "Next Available Unit"...

Finding No. 2024-004 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner did not make available to HOME tenants the contracted number and type of HOME units. This is considered a temporary noncompliance as follows: "Next Available Unit" rule: The owner must rent the next comparable or smaller unit that becomes vacant to a low-income household. Temporary noncompliance: The unit is temporarily out of compliance with HOME requirements, but the property can regain compliance by following the "next available unit" rule. Unit conversion: If the owner fails to comply and rents a comparable vacant unit to a non-low-income tenant, the over-income unit loses its low-income status and the building's compliance is reduced. A two bedroom unit did become available in 2024 and this tenant was not relocated. Corrective Action Plan A new review process is in placed to review the HOME units that will be re-classified the next time there is a vacant unit of the corresponding size/type.

View Audit 373851

Finding 1164419 (2024-003)

Material Weakness 2024

Reach Community Development, Inc.

OR

Eligibility HUD Housing Programs Significant Deficiency

Finding No. 2024-003 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner did not make available to HOME tenants the contracted number and type of HOME units. Corrective Action Plan A new process is in placed to review HOME unit count wh...

Finding No. 2024-003 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner did not make available to HOME tenants the contracted number and type of HOME units. Corrective Action Plan A new process is in placed to review HOME unit count when a unit becomes available.

View Audit 373851

Finding 1164418 (2024-002)

Material Weakness 2024

Reach Community Development, Inc.

OR

Eligibility HUD Housing Programs Significant Deficiency

Finding No. 2024-002 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition In connection with our lease file review, we noted six instances of eight tenants tested where management did not provide support that they performed a 3rd party income veri...

Finding No. 2024-002 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition In connection with our lease file review, we noted six instances of eight tenants tested where management did not provide support that they performed a 3rd party income verification in accordance with policy. Corrective Action Plan As a result of the 2024 audit, a new process is set up to ensure that new employees receive HUD annual training. Management will continue to ensure that 3rd party income verification is performed in accordance with policy.

View Audit 373851

Finding 1163555 (2024-003)

Material Weakness 2024

Community Service Council of Greater Tulsa, Inc.

OK

Eligibility Significant Deficiency

Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide Section VIII, Subsection E. Documentation Required states: Grantees must use adequate financial management s...

Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide Section VIII, Subsection E. Documentation Required states: Grantees must use adequate financial management systems that follow generally accepted accounting principles (GAAP) and provide adequate fiscal control and account records including cost accounting records supported by documentation. Grantees must also maintain all back up documentation and invoices to support the costs paid with SSVF funds.” Condition: During the OBO review, OBO found the Organization was unable to provide a general ledger detail that separated administrative costs from general costs. Cause: Because the Organization’s SSVF administrative costs are allocated payroll expenses, management was unaware they needed to segregate the administrative costs in the general ledger. Effect: The Organization’s failure to provide a general ledger that separates administrative and general expenses increases the risk of inaccurate financial results being provided at closeout or unauthorized and ineligible expenses being charged to the award, which may result in subsequent funding shortages for other qualified expenses. Questioned Costs: None Identification as a repeat finding: This is a repeat finding. Corrective Action: As of 2/17/2025 OKVU added sub-coding to the general ledger to identify administrative labor costs under 7000 – Salaries & wages, 7100 – Fringe benefits and 7200 – Payroll taxes bases on direct allocations provided to the payroll system. This information will be provided by report from the payroll system and added via journal entry to the GL.

View Audit 373239

Finding 1163553 (2024-001)

Material Weakness 2024

Community Service Council of Greater Tulsa, Inc.

OK

Eligibility Significant Deficiency

Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide (March 2021) Section V, Subsection C. Determining Income Eligibility, provides a summary of asset inclusions...

Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide (March 2021) Section V, Subsection C. Determining Income Eligibility, provides a summary of asset inclusions and exclusions for use in evaluating assets. Assets must be evaluated at entry to SSVF and at recertification. Condition: The Office of Business Oversight (OBO) performed a review to assess the Organization’s compliance with SSVF program and other federal requirements and regulations. During this review, OBO found 45 case files missing evidence that the grantee evaluated assets (inclusions and exclusions) for certification of eligibility. Cause: Management misinterpreted the guidance and was not aware of the need to document asset evaluations if the veteran did not have any assets. Effect: The Organization’s failure to obtain and keep the adequate income supporting documentation in the case file may result in the Organization providing services to an ineligible veteran or household. Questioned Costs: None Identification as a repeat finding: This is a repeat finding. Corrective Action: As of 12/06/2024 OKVU implemented the addition of the Asset Calculation Worksheet to the veteran case file. To ensure compliance the requirement was also added to the discharge file QC checklist and the SSVF policy and procedure manual updated. As of 12/11/2024 all case manager staff were provided training.

View Audit 373239

Finding 1162906 (2024-008)

Material Weakness 2024

City of Peabody

MA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the education stabilization grant for 2026, as well as into future periods.

View Audit 372554 Questioned Costs: $1

Finding 1162896 (2024-007)

Material Weakness 2024

City of Peabody

MA

Allowable Costs / Cost Principles Eligibility Material Weakness

Views of Responsible Officials and Planned Corrective Actions: The School District will implement internal control procedures to ensure that the required documentation is completed, retained and maintained in an organized manner. Management plans to implement these procedures in 2026.

View Audit 372554

Finding 1162893 (2024-006)

Material Weakness 2024

City of Peabody

MA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the Title I grant for 2026, as well as into future periods.

View Audit 372554 Questioned Costs: $1

Finding 1162890 (2024-005)

Material Weakness 2024

City of Peabody

MA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the special education grant for 2026, as well as into future periods.

View Audit 372554 Questioned Costs: $1

Finding 1162755 (2024-004)

Material Weakness 2024

Community Action Agency of Talladega Clay Randolph Calhoun and Cleburn

AL

Internal Control / Segregation of Duties Eligibility Reporting § 200.512

To ensure the audit is submitted in a timely manner, and on time, we will begin at the beginning of the year.

View Audit 372376

Finding 1162690 (2024-002)

Material Weakness 2024

City of New Rochelle

NY

Eligibility

Name of Auditee: City of New Rochelle, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: Edward Ritter, Commissioner of Finance Phone: (914) 654-2000 (2) Audit Finding 2024-002 - The City did not follow controls for eligibi...

Name of Auditee: City of New Rochelle, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: Edward Ritter, Commissioner of Finance Phone: (914) 654-2000 (2) Audit Finding 2024-002 - The City did not follow controls for eligibility certifications of individuals enrolled in the HIPP-RAP. (a) Implementation Plan of Actions - Management has initiated a full review and recertification of all participants in the HIPP-RAP to determine if any additional participants were missing eligibility determinations. (b) Implementation Date - This will be implemented and completed for the year ended December 31, 2025. (c) Persons Responsible for Implementation - The Commissioner of Development and the City Council.

View Audit 372331

Finding 1162410 (2024-002)

Material Weakness 2024

Inova Health System

VA

Subrecipient Monitoring Eligibility Reporting

Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award P...

Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials: Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility. Corrective Action Planned: Inova will comply with VDH's 24-month eligibility rule, ensuring that services are not provided to RWHAP clients who miss their reassessment. To prevent gaps in service, Inova will continue to maintain monthly expiring eligibility tracking sheet to ensure clients will receive reminders 30–45 days before their eligibility period ends. CAR reviews will continue periodically throughout the 24 month timeframe. Inova will transition to HRSA’s CareWare system for eligibility management and tracking. Inova will continue 100% internal monthly eligibility audits and peer reviews, as well as implement a 10% chart review by a team member outside of the Juniper Program. Clients who do not submit the required reassessment documents will be removed from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.

View Audit 372193

Finding 1162368 (2024-006)

Material Weakness 2024

Housing Authority of the City of Newark

NJ

Questioned Costs Eligibility HUD Housing Programs

Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Execu...

Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.

View Audit 372175 Questioned Costs: $1

Finding 1162309 (2024-003)

Material Weakness 2024

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Special Tests & Provisions Subrecipient Monitoring Eligibility

Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learnin...

Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learning and development. The Slide Fee Coordinator will run a daily report to audit the slide fees entered the previous day to ensure accuracy.

View Audit 372119

Finding 1162290 (2024-003)

Material Weakness 2024

Waikiki Health

HI

Special Tests & Provisions Subrecipient Monitoring Eligibility

Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a find...

Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a finding in the 2023 Audit. In response to the audit finding, I worked directly with the Director of Clinical Operations and the Patient Service Representative Manager to conduct a comprehensive review of the health center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and the definition of family size. We developed and implemented a step-by-step standard operating procedure (SOP) for Patient Service Representatives (PSR) staff to consistently assess and apply sliding fee discounts. The SOP included clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director's management team will conduct quarterly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to leadership and provide corrective follow-up and provide training for PSR personnel on the updated policy and procedures needed. I reported all identified and assessed changes to the health center's board of directors or its audit committee for review and oversight. The board verified that appropriate corrective action was being taken regarding internal controls.

View Audit 372114

Finding 1162272 (2024-002)

Material Weakness 2024

Centerplace Health, Inc.

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility

Finding 2024-002 – Special Tests and Provisions The Organization did not properly determine the sliding fee discount given to patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Since this occurrence, a new position has been created and staffed- ...

Finding 2024-002 – Special Tests and Provisions The Organization did not properly determine the sliding fee discount given to patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Since this occurrence, a new position has been created and staffed- Patient Service Representative Team Lead. This staff member oversees and trains the Patient Service Representatives in their responsibilities, including the sliding fee discount schedule application and compliance. A focus of this newly created position is training and compliance of the sliding fee schedule throughout all the clinics, which is ongoing from Oct. 15, 2024. The Patient Service Team Lead will be supervised by the Revenue Cycle Manager as part of the Finance Department reporting to the Interim CEO Bob Rodriguez, who will oversee this effort. The new position and implementation of training to correct the finding commenced Oct. 15, 2024.

View Audit 372079

Finding 1162261 (2024-001)

Material Weakness 2024

Astronomical Scoiety of the Pacific

CA

Eligibility Reporting Internal Control / Segregation of Duties § 200.512

Management concurs with the finding and has already implemented a compliance tracking system. A new policy was adopted during FY 2025 to ensure timely submissions moving forward. Contract Person: Brett Metzger, Outside Consultant Completion Date: November 11, 2025

View Audit 372071

Finding 1162234 (2024-007)

Material Weakness 2024

Fair Haven, Inc.

IN

Reporting Eligibility § 200.512

Views of Responsible Officials and Planned Corrective Actions: Management agrees timeliness is critical. Corrective Action: Maintain an audit compliance calendar with key federal deadlines and internal milestone tracking.

View Audit 372043

Finding 1162233 (2024-006)

Material Weakness 2024

Fair Haven, Inc.

IN

Procurement, Suspension & Debarment Eligibility § 200.214

Views of Responsible Officials and Planned Corrective Actions: Management agrees documentation must be retained. Corrective Action: Management has implemented a formal process to document vendor eligibility verficiation. As of FY 2025, all vendors are revewied in SAM. gov prior to payment or contrac...

Views of Responsible Officials and Planned Corrective Actions: Management agrees documentation must be retained. Corrective Action: Management has implemented a formal process to document vendor eligibility verficiation. As of FY 2025, all vendors are revewied in SAM. gov prior to payment or contract execution, and a screenshot or PDF of the verification is saved to the Vendor Verification Log. The Grants & Finance Manager maintains this documentation as part of the procurement file.

View Audit 372043

Finding 1162153 (2024-001)

Material Weakness 2024

Boston Tremont Housing Development Fund Corporation

NY

HUD Housing Programs Eligibility

Management has addressed the issue by recertifying the tenants and does not expect late recertifications to occur again.

View Audit 371944

Finding 1162014 (2024-008)

Material Weakness 2024

Bill Wilson Center

CA

Questioned Costs Eligibility Material Weakness

For ALN 16.575 Crime Victim Assistance There was a staffing change for the program after FY23-24. Since the new Program Manager joined in December 2023, she worked with her team to put together the following procedures and protocols: For direct program expenses, all copies of rent payment requests, ...

For ALN 16.575 Crime Victim Assistance There was a staffing change for the program after FY23-24. Since the new Program Manager joined in December 2023, she worked with her team to put together the following procedures and protocols: For direct program expenses, all copies of rent payment requests, check stubs and client signed half sheets are retained. Client support purchases have original receipts. For proof of client eligibility, the previous management team kept the files in paper format. The new management team saved all the copies of client IDs, birth certificates or passports in AWARDS to verify age of participants. Client agreements are saved electronically in AWARDS. Paper copies are stored in locked cabinets as well. All time entries are reviewed, approved, submitted, processed and saved in Paycom.

View Audit 371876 Questioned Costs: $1

Corrective Action Plans

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